LEGISLATION STUDY on EMERGENCY MEDICAL CARE SYSTEMS in

LEGISLATION STUDY on EMERGENCY MEDICAL CARE SYSTEMS in the ENGLISH-SPEAKING CARIBBEAN Area of Health Systems based on Primary Health Care Pan American Health Organization/World Health Organization PAHO/WHO

LEGISLATION STUDY on EMERGENCY MEDICAL CARE SYSTEMS in the ENGLISH-SPEAKING CARIBBEAN May 2010 Research and Analisys: Sylvia G. Moss, B.A., LL.B. (UWI) L.E.C. Hugh Wooding Law School Advanced Dip. Legislative Drafting (UWI) Fellow C.I.L.I.P. (Gt. Brit.) Coordinated by: Mónica Bolis and Reynaldo Holder Area of Health Systems based on Primary Health Care, Pan American Health Organization/World Health Organization (PAHO/WHO) with the financial support of: the Spanish Agency for International Cooperation (AECI) Area of Health Systems based on Primary Health Care (HSS) Pan American Health Organization/World Health Organization PAHO/WHO

Legislation Study on Emergency Medical Care Systems in the English-Speaking Caribbean. Washington, D.C.: PAHO, 2010. 19 pgs. PAHO/HSS/HR&SP/2010/005 Pan American Health Organization, 2010 The Pan American Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and inquiries should be addressed to the Area of Health Systems based on Primary Health Care, Pan American Health Organization, Washington, D.C., U.S.A. which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The authors alone are responsible for the views expressed in this publication. Design and Layout: Matilde E. Molina

TABLE OF CONTENTS EXECUTIVE SUMMARY...5 PART 1...7 PART 2...9 ANGUILLA...10 THE BAHAMAS...11 BARBADOS...15 BELIZE...17 BRITISH VIRGIN ISLANDS...17 DOMINICA...17 GRENADA...17 GUYANA...18 JAMAICA...18 MONTSERRAT...19 SAINT KITTS AND NEVIS...20 SAINT LUCIA...20 SAINT VINCENT AND THE GRENADINES...21 TRINIDAD AND TOBAGO...21 PART 3...23 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN iii

EXECUTIVE SUMMARY A search through the relevant legislation held at the Faculty of Law Library of the University of the West Indies Cave Hill reveals that only the Bahamas and Trinidad and Tobago have emergency medical care systems legislation : in the Bahamas, The Heath Professionals (General) Regulation, 2000 Part VIII, Emergency Services Technology under section 20 of the Public Hospitals Authority Act, 1998 (Chapter 234); and in Trinidad and Tobago The Emergency Ambulance Services and Emergency Medical Personnel Act, 2009 (Act No. 8 of 2009). However, some countries which have not yet enacted such legislation have well organized emergency medical service / emergency ambulance service facilities. In Barbados, for example, pre-hospital emergency ambulance service is organized and administered under a specialist Accident and Emergency physician who is responsible for the medical direction and training of emergency medical dispatchers, emergency medical technicians, paramedics who are advanced emergency medical technicians, and support staff. The Emergency Ambulance Services Department is a Department of the Queen Elizabeth Hospital a government funded, organized and administered institution. The Emergency Ambulance Service is closely linked to the Accident and Emergency Department to which all patients are ultimately transported. In contrast to the Barbados situation, in Belize the Emergency Response Team (BERT), a non-profit, non-governmental organization specializes in pre-hospital care in the form of emergency response and transportation. BERT responds to all medical emergencies and provides ambulance transfer services between medical facilities. Its ambulance personnel are extensively trained to nationally and internationally accepted standards, and collaborate and coordinate with all local health care facilities to ensure the best possible patient care. Part 1 of the Paper is a preliminary section stating the objectives of the study, its methodology and variables of analysis, and sources of information utilized, as well as its structural requirements as set out in the contractual document. Challenges posed are identified. Part 2 of the Paper outlines the findings of the study. In the majority of cases, although countries and territories may have pre-hospital emergency medical ambulance service, such services are not supported by legislative enactments. The supportive role that emergency ambulance service can provide in the disaster preparedness and response context of the English-speaking Caribbean is noted. Part 3 of the Paper gives general conclusions on findings. LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 1

PART 1 The Scope of Services of this Legislation Study on emergency medical care systems defines emergency medical systems as including medical care, transfer of patients, and communication services needed to provide health care in the event of an emergency. Essentially, therefore, an emergency medical system is dedicated to providing out-of-hospital acute medical care and transport to persons with illnesses or injuries which the patient or the medical practitioner involved believe to constitute a medical emergency. In the English-speaking Caribbean emergency medical care systems are generally referred to as emergency ambulance service. An emergency ambulance service provides a measure of pre-hospital medical care and transports the injured person to the Accident and Emergency Department of a hospital with such a facility. As is pointed out in Barnett, Segree and Matthews s paper The Roles and Responsibilities of Physicians in Pre-Hospital Emergency Medical Services: A Caribbean Perspective, a Pre-Hospital Emergency Medical Service (PHEMS) is a vital component of a country s health service, since it provides early medical care to critically ill and injured persons in the field. Barnett, Segree and Matthews explain that a Pre-Hospital Emergency Medical Service refers to a service that responds to specific health needs of a person outside of a hospital setting. These needs include, but are not limited to, attention to acute life-threatening events, transportation of ill or injured persons to special facilities for investigation and treatment, inter-facility movement of the ill and injured, and standby assignments at events that pose health risks to participants or spectators. The countries and territories involved in this Study are: Anguilla, Antigua and Barbuda, Bahamas, Barbados, Belize, British Virgin Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Lucia, St. Kitts and Nevis, St. Vincent and the Grenadines, and Trinidad and Tobago. The Methodology adopted involved primarily a search through legislation in the University of the West Indies Faculty of Law Library, Cave Hill, Barbados. Assistance was also sought from the Librarian or the Pan American Heath Organization / World Health Organization, Office of Caribbean Program Coordination and from the Librarian of the Queen Elizabeth Hospital Library who were able to offer only minimal assistance. Internet searches, and correspondence with disaster preparedness, management and response agencies were also included in the methodology with varying degrees of success Since such legislative provisions as exist for the most part deal with general care rather than health care delivered via emergency medial systems, challenges were posed by those aspects of the variables which required that the legislation identified be examined under the Head: Structure of the emergency medical systems, Subheads: a. Role of the National Health Authority (stewardship); b. Quality assurances for ambulatory and institutional medical care: services, infrastructure, equipment, human resources, compliance with at least the basic requirements of the medical speciality and the different grades of complexity; LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 3

c. Emergency number: type and characteristics universality, language accessible (national and foreign languages, if applicable important in countries hosting tourism); emergency calls recording; d. Transfers of patients to other medical care institutions or to the patient s residence; land, air and sea ambulances services; e. Standards for emergency care, clinical history and prescriptions; f. Emergency care financing, and g. Refund of the emergency care expenditures, if applicable insurance schemes. A National Health Authority is responsible for the management of all hospitals established and funded by the Government, and embraces the entire gamut of sub-heads set out in sub-section b to g whether or not specifically set out in the National Health Authority Act, or provided for in Statutory Instruments displayed in the Statute Book. In other words, such an Act while empowering the Health Minister or some other official to prepare Regulations, Rules, Orders, Standards or other type of Statutory Instrument to deal with the subject in question, does not mandate that all or any of such instruments be brought into being by legislation. For example, the Regional Health Authorities Act, 2005 (Act No. 4 of 2005) of Guyana establishes regional health authorities with responsibility for the delivery of and administering health services and health programmes in specified geographic areas and for matters incidental thereto and connected therewith, but it does not set out what those services and health programmes should be. This Act provides for the establishment of a Board, and empowers the Board to establish a professional advisory committee to advise the Board with respect to clinical care and health issues; with respect to criteria for admission and discharge of patients; with respect to quality assurance and management; with respect to the health services and health programmes delivered in the regional health authority; and with respect to any other issue that the board may refer to the committee. It is thus well within the legal mandate of the Board, through its professional advisory committee and its legal health authorities, to establish emergency medical care systems, even though the Act is silent on the matter. It should also be noted that the Ministry of Health Act, 2005 (Act No. 6 of 2005) of Guyana states that the Ministry of Health is to deliver and where necessary oversee the delivery of health care throughout Guyana and to effect plans and policies, monitor quality and evaluate outcomes. Note that in the National Health Sector Strategy of Guyana mention is made of improving capacity to respond to emergencies, disasters, climate change and environmental health risks; and to intensifying efforts by the Ministry of Health to deploy modern legislation, regulations and licensing, using professional codes of ethics, patient charters, standards and guidelines. Attention has been drawn to the National Health Sector Strategy of Guyana precisely because no legislation has been found relating to emergency ambulance service. However, it is clear that Guyana is cognizant of its legislative shortcomings as is evidenced by the contents of its National Health Sector Strategy. Insurance schemes and other financial arrangements are normally the subject of distinct and separate legislation. 4 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN

PART 2 A search through the relevant legislation held at the Faculty of Law Library of the University of the West Indies Cave Hill reveals that only the Bahamas and Trinidad and Tobago have emergency medical care systems legislation: in the Bahamas, The Heath Professionals (General) Regulation, 2000 Part VIII, Emergency Services Technology under section 20 of the Public Hospitals Authority Act, 1998 (Chapter 234); and in Trinidad and Tobago The Emergency Ambulance Services and Emergency Medical Personnel Act, 2009 (Act No. 8 of 2009). However, some territories which have not yet enacted such legislation have well organized emergency medical service / emergency ambulance service facilities. To understand this situation, one must recall that this Study focuses on legislation, and given that the countries covered by this Study are all common law jurisdictions in which responsibility for the provision of all aspects of health care services lie with the Minister responsible for Health and the Ministry of Health. It logically follows therefore, that emergency ambulance service in each of the jurisdictions falls under the aegis of the Ministry of Health, which either itself provides the service or makes use of privately provided ambulance services which have been duly registered and recognized by the Ministry. Since all hospitals are regulated under legislative enactments empowering the Minister of Health and the Ministry of Health with responsibility for the management and development of the health system, it follows that the Minister of Health and the Health Ministry s responsibilities include hospitals, emergency ambulance services and by extension most factors directly affecting the health of the population. In other words, the Minister of Health is both the provider of health care systems and the regulator of the sector. With the exception of Trinidad and Tobago s Emergency Ambulance Services and Emergency Medical Personnel Act, 2009 (Act No. 8 of 2009), there is no single piece of legislation in the English-speaking Caribbean specifically dealing with emergency ambulance service. This absence of specific legislation may be viewed as an indication that a more formal organization of the system is necessary, and indeed there is evidence that regional efforts are being made towards this end. A news item emanating from Belmopan, Belize, as reported in the online news-service Caribbean Net News of December 16, 2009, stated that the Belize Health Minister had chaired a meeting comprising representatives from the World health Organization, the Inter American Bank, the University of Puerto Rico, Emory University and Dalhousie University at which the founding of the Caribbean Health Outcome Improvement Programme was discussed. The expectation was that, at the conclusion of the meeting, definitive terms of reference would be developed to collaborate closely with agencies including the Pan American Health Organization, WHO, CARICOM and the Caribbean Public Health Agency. The Caribbean Health Outcome Improvement Programme was being designed and launched as a result of the unanimous resolution made by the Caucus of CARICOM Ministers Responsible for Health on September 27, 2009. It may reasonably be hoped that the enactment of provisions for emergency ambulance services under appropriate legislation will attract the Programme s attention. In 2003 the Pan American Health Organization published the book entitled Emergency Medical Services Systems Development: Lessons learned from the United States of America for Developing Countries. To quote from PAHO s annotation to the online version of the study: It is anticipated LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 5

that policy makers in health and public safety ministries, national emergency commissions, nongovernmental organizations, and other bodies charged with the responsibility of establishing, overseeing, or providing EMS care can use this document as a frame of reference when designing their system s model.. To reiterate, in the English-speaking Caribbean responsibility for the provision of health care services lies with the Minister responsible for Health and therefore, inevitably, the emergency ambulance service when provided by the Ministry is an integral part of health care services positioned under the jurisdiction of the Ministry of Health, whether that service is provided directly by the Ministry of Health or by the Ministry s registration of privately provided emergency ambulance service. A good case-study of a representative example of this relationship is to be found in Dr. R. P. Naidu s 1991 paper entitled Development of Emergency Medical Services in Barbados, in which the origins of the Emergency Ambulance Service and the services offered by the Accident and Emergency Department of the Queen Elizabeth Hospital are set out. ANGUILLA The National Health Authority of Anguilla Act, includes the following definition which is relevant to this Paper: health service mean a service provided by the Authority to an individual (b) by an emergency medical technician or paramedic. Minister means the member of the Executive Council with responsibility for health. Regarding the powers of the Minister, Section 2 (1) states that on the recommendation of the Minister, the Governor in Council may establish a Strategic Plan for Health for Anguilla; and (2) The Minister is responsible under this Act for the implementation of the Strategic Plan for Health in relation to the Authority. Section 4, established the Health Authority of Anguilla, which has among its responsibilities: to promote and protect the health of persons in Anguilla and to work towards the prevention of disease and injury in Anguilla; to assess on an ongoing basis the health needs of persons in Anguilla; to determine the priorities in the provision of health care to persons in Anguilla to ensure that the most appropriate health services are provided; and to collaborate with educational institutions, such as the University of the West Indies, in providing education, training and research in health care. Section 6 states that subject to this Act and its regulations or any other Act and its regulations, the Authority has the power to do all things necessary for, or ancillary or incidental to, the carrying out of the responsibilities under this Act or any other enactment. Section 7 states that the affairs of the Authority shall be managed by a Board consisting of 7 members appointed by the Minister. Section 48 states that the Governor in Council may make Regulations for the better carrying out of this Act. The Disaster Management Act, 2007 of Anguilla appoints a Director of Disaster Management responsible to the Governor in Council for coordinating the general policy of the Government relating to the mitigation of, preparedness for, response to and recovery from emergencies and disasters in Anguilla. Among the functions of the Director is to provide technical advice on draft regulations, whether under this Act or any other legislation, relating to the mitigation of, preparedness for, response to and recovery from emergencies and disasters in Anguilla. The Act also establishes a National Disaster Management Advisory Committee to advise the Governor in Council on the policies respecting disaster management and all other matters incidental to or relating to disaster management under this 6 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN

Act. The Director shall prepare annually a National Disaster Management Plan which shall include, among other things, procedures for the provision of medical care in the event of disaster emergency. THE BAHAMAS In the Bahamas the Public Hospital Authority is guided by strategic directions and goals defined by the Ministry of Health. It works in conjunction with the Ministry of Health and its agencies (the Public Health Department, and the Department of Environmental Health Services) to achieve targets for the public sector health services system, as identified in the Health Services Strategic Plan. As an independent public entity, the Public Hospitals Authority is governed by a Board of Directors, headed by a Chairman appointed by and directly accountable to the Minister of Health. The Public Hospitals Authority Act 1998 (Act No. 32 of 1998) Chapter 234 is described as: An Act to provide for the establishment of a body corporate to be known as the Public Hospitals Authority and for the functions relating to that Authority and to make provisions in respect of matters connected therewith or ancillary thereto. Section 3 of the Act establishes the Public Hospitals Authority responsible for the management of the hospitals known as the Princess Margaret Hospital, the Rand Memorial Hospital and the Sandilands Rehabilitation Centre. Section 5 sets out the functions of the Authority, among which functions are: to control, regulate and administer all matters related to the management of any hospital; to ensure the application of efficient and appropriate techniques, systems and standards for the delivery of health care in the hospitals; to fix qualifications and terms and conditions of service relating to its employees; to consult with the Minister responsible for health on matters of national health policy and capital development programmes for the hospitals; to establish and development relationships with national, regional and international bodies engaged in similar of ancillary pursuits; to collaborate with educational institutions, such as the University of the West Indies and any other recognized training institution in the education and training of persons and in research in medicine, nursing, dentistry, pharmacy and biomedical and health science fields, as well as any related ancillary and supportive fields. The Princess Margaret Hospital and the Rand Memorial Hospital both have Accident and Emergency Departments. In addition to its mandate for public hospitals, the Public Hospitals Authority is also charged with responsibilities for the National Emergency Medical Services (NEMS), under the delegated authority of the Minister responsible for Health, The Public Hospitals Authority Act, 1998 (Chapter 234) Section 7, establishes a Board of Directors of the Authority. The Board is the governing body of the Authority and performs the functions and exercises the powers of the Authority. Section 19 of the Act provides that the Authority, subject to the approval of the Minister, may make regulations generally for the better execution and carrying out of the objects of this Act. Section 20 (1) of the Act states that the Minister may give to the Authority directions of a general or of a specific nature as to the policy to be followed by the Authority in the carrying out or pursuit of its functions as appears to the Minister requisite in the public interest, and that the Authority shall give effect to any such directions. Part VIII, Emergency Services Technology of the Health Professionals (General) Regulations, 2000, made under Section 20 of the Public Hospitals Authority Act, 1998 (Chapter 234), offers the following definitions. LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 7

In Section 24 which is its Interpretation Section: ambulance service means a person, agency or enterprise that is approved by the Minister to provide ambulance service in the Commonwealth of the Bahamas; basic life support means patient care practices that are not controlled medical acts; controlled medical Act means a medical act that can be delegated by a medical practitioner to a person licensed as an emergency services technician advanced; medical advisor means a medical practitioner who is appointed, employed or otherwise engaged by a training institution to provide medical over-sight and advice in regard to training to perform controlled medical acts; medical direction means the provision of direct on line medical control by a medical director or his or her designate or indirect supervision that follows standard protocols established by the medical director and approved by the Council and the provision of medical quality assurance by a medical practitioner, of the patient care practices and controlled medical acts performed by emergency services technicians operating in, employed by, or engaged as volunteers in an ambulance service; medical director means a medical practitioner with postgraduate training in emergency medicine, anaesthesia, critical care, surgery or cardiology, appointed, employed or otherwise engaged to provide medical direction to emergency services technicians employed, operating in or engaged as a volunteer by a person, agency or enterprise that provides ambulance service; Section 25 states the scope of practice as follows: The practice of emergency services technology is the provision of pre-hospital emergency care and transportation to the ill and injured while operating, employed in, or acting as a volunteer with an ambulance service. Section 26 sets out authorized health services as follows: (1) In the course of engaging in the practice of emergency services technology as an emergency services technician basic a person may, subject to the terms, conditions and limitations imposed on his or her certificate of registration, perform the following basic life support patient care and transportation skills with respect to an ill or injured person (a) assessing and managing the scene of a health emergency situation; (b) performing a primary patient survey; (c) providing basic airway management techniques; (d) taking a current and past history relevant to the emergency event; (e) assessing the emergency health status of the person and determining a need for and the priority for care and transportation; (f) assessing, evaluating and recording the vital signs of a patient including blood pressure, pulse rate, rhythm and volume, respiratory rate, level of consciousness and skin condition and colour; 8 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN

(g) maintaining the airway by manual manipulation or use of oral or nasal-pharyngeal airways; (h) manually ventilating a patient by mouth-to-mouth or bag-valve ventilator; (i) (j) performing cardiopulmonary resuscitation for an adult, child or infant; administering oxygen by flow meter; (k) suctioning of the mouth and oral-pharynx; (l) recognizing external hemorrhage and apply basic management techniques; (m) bandaging and general care of wounds and environmental injuries; (n) splinting and otherwise immobilizing the body or parts of the body where fracture or injury to a joint may reasonably be suspected; (o) administering oral glucose for conscious hypoglycemic patients; (p) managing a patient experiencing a psychological or emotional crisis; (q) using lifting and moving technique to safely move or position a patient; (r) (s) (t) providing patient care in a sanitary and safe environment for both the patient and the technician; protecting the confidence and dignity of the patient; recording of all pertinent information that may impact on the welfare and continuing care of the patient; (u) providing concise and accurate patient status and care reports to receiving health care facility staff and physicians, and (v) operating an emergency vehicle in a manner that is consistent with the needs of the patient and in the interest of public safety. (2) In the course of engaging in the practice of emergency services technology as an emergency medical services technician intermediate a person may, subject to the terms, conditions and limitations imposed on his or her certificate of registration, perform all of the skills referred to in paragraph (1) and perform the following patient care skills in respect to an ill and injured person (a) auscultation of the chest and recognizing and evaluating breath sounds; (b) auscultation and palpitation of the abdomen; (c) automated external cardiac defibrillation; (d) intravenous cannulation; (e) maintain peripheral intravenous locks and infusions of fluid for simple fluid replacement or to keep a vein open; LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 9

(f) (g) take of blood sample from a peripheral vein; administer under medical direction, epinephrine subcutaneously for anaphylaxis, salbutamol inhalations for respiratory distress, nitroglycerine sublingually for angina, aspirin for patients suspected of suffering myocardial infarction or intravenous glucose for hypoglycemia under medical direction; (h) use advanced airway management techniques including foreign body removal by direct techniques; and use of devices that do not pass the glottis; (i) (j) use pulse oximeter and evaluation of findings; and use end tidal carbon dioxide monitors and evaluating the findings. (3) In the course of engaging in the practice of emergency services technology as an emergency medical services technician advanced a person may, subject to the terms, conditions and limitations imposed on his or her certificate of registration, perform all of the skills referred to in paragraphs (1) and (2) and perform the following patient care skills in respect of an ill and injured person (a) administer advanced cardiac drugs and other emergency drugs in accordance with protocols approved by the Council; (b) administer emergency drugs for childbirth, medical conditions and trauma in accordance with protocols approved by the Council; (c) perform endotracheal and nasotracheal intubulation; (d) perform needle cricothyroidotomy and thoracostomy; (e) perform cardiac monitoring and rhythm interpretation; (f) perform manual external cardiac defibrillation; (g) perform electrical cardioversion; (h) perform transthoracic cardiac pacing; (i) suction below the glottis; (j) perform urinary catheterization; (k) utilize intravenous infusion pumps; (l) provide care for drainage tubes and feeding tubes; (m) provide care during transport of chest tubes and chest drainage; and (n) use automated ventilators. Section 27 deals with Qualifications and Registration; and Section 28 is concerned with Training Institution. Section 29 sets out in detail the Training Institutions Requirements, as follows:. 10 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN

29(1) An agency or institution providing training for persons seeking to be registered under this Part shall (a) have a medical advisor who provides medical oversight and supervision of the patient care components of the training program; approves of the medical content of the training program and its delivery; approves of the valuation methodology utilized to confirm competency to provide patient care to the level of training; (b) have one or more course coordinators who for the emergency services technician basic course hold an emergency services technician intermediate certificate from an accredited institution and have a least three (3) years experience as an emergency services technician intermediate or experience that the Council considers equivalent thereto; for the emergency services technician intermediate course hold an emergency services technician advanced certificate from an accredited institution and have at least three (3) years experience as an emergency services technician advanced or experience that the Council considers equivalent thereto; and for the emergency services technician advanced course hold an emergency services technician advanced certificate from an accredited institution, have at least five (5) years experience as an emergency services technician advanced or experience that the Council considers equivalent thereto and hold an emergency services technician instructor s certificate from an accredited institution. (c) have a competency based curriculum of study and training for emergency services technician basic, emergency services technician intermediate and emergency services technician advanced so as to prepare a student to provide each skill required to be licensed in the applicable category under the Act; (d) demonstrate the presence and utilization of a continuous quality improvement process for the emergency services technician training program being provided; and (e) make available for public scrutiny a written description of the training program content and educational methodologies and evaluation criteria utilized to ensure graduates are adequately prepared for licensure under these Regulations. 29(2) Where a training institution is a hospital licensed under the Hospitals and Health Care Facilities Act, 1998 (Chapter 235) the medical advisor of the hospital shall be deemed to be the medical advisor of the training institution for the purposes of paragraph (1). In the Bahamas there also exists the Bahamas Telemedicine Group Ltd. (BTG), which provides 24-hour emergency medical care throughout the islands of the Bahamas. All of their physicians are Emergency Medicine specialists with expertise in assessing, managing and where necessary coordinating the evacuation of a patient experiencing a medical emergency. BARBADOS The Queen Elizabeth Hospital Act (Chapter 54) of Barbados, is an Act to provide for the administration of the Queen Elizabeth Hospital, the establishment of a Board of Management, and for related matters. Section 23 provides that the Board of Management may, with the approval of the LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 11

Minister, make Regulations for among other things prescribing the services to be provided by or at the Hospital. The Health Services Act (Chapter 44) is described as an Act relating to the promotion and preservation of the health of the inhabitants of Barbados. The latter Act provides in Section 8(1) that the Minister responsible for Health may establish such Boards and Committees as he may think fit for the purpose of this Act, consisting of members to be appointed by him and may if he thinks it expedient revoke the appointment of any such member. Section 8(2) states that the constitution of every such Board or Committee shall be settled by the Minister. Section 10(1) empowers the Minister to make regulations for the proper carrying into effect of this Act. Broad and generous interpretation of these two health Act would recognize the Minister of Health and the Health Ministry as empowered to establish the Barbados emergency ambulance service which is operated by the Queen Elizabeth Hospital, even though no explicit Act or Regulation appears on the statute book. Emergency medical technicians and paramedics are trained personnel and the Emergency Ambulance Service Department is headed by a doctor who is a specialist in emergency medicine. The Department is responsible for establishing standards for licensing and training of personnel, and for the treatment of acutely ill or injured persons by ambulance and rescue personnel. The emergency ambulance service in Barbados is operated by the Queen Elizabeth Hospital and can be called upon in the event of an emergency. The Queen Elizabeth Hospital is the only major trauma facility in Barbados with a 24-hour accident and emergency room. The Queen Elizabeth Hospital ambulance crews cooperate with the Barbados Defence Force ambulance service if any mass casualty arises. The ambulance crews are permitted to perform the CPR, and advanced cardiac support as well as administer IVs. The Medical Consultant and Director of the Emergency Ambulance Service Department of the Queen Elizabeth Hospital is a specialist Accident and Emergency Physician. He is responsible for the medical direction and training for emergency medical dispatchers, Emergency Medical Technicians (EMTs), Paramedics (who are advanced trained EMTs) and support staff. In addition to the Queen Elizabeth Hospital, the FHM Emergency Medical Clinic provides complete private emergency services, and the doctors are all specialized in accident and emergency care. The Queen Elizabeth Hospital is well-equipped and doubles as a teaching hospital. At the hospital, the School of Clinical Medicine and Research (SCMR), an affiliate of the University of the West Indies (UWI) Cave Hill campus, offers post graduate programmes which include accident and emergency medicine. Courses in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACIS) are offered by the Heart and Stroke Foundation of Barbados. The Medical Consultant and Director of the Emergency Ambulance Service Department of the Queen Elizabeth Hospital is a specialist Accident and Emergency Physician. He is responsible for the medical direction and training for emergency medical dispatchers, Emergency Medical Technicians (EMTs), paramedics (who are advanced trained EMTs) and support staff. 12 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN

BELIZE Belize s Emergency Response Team (BERT) is a non-profit, non-governmental organization. BERT specializes in pre-hospital care in the form of emergency response and transportation. As stated on its Internet web page, BERT is the only qualified provider in the country of Belize, offering emergency response service twenty-four hours per day, three hundred and sixty-five days per year. BERT responds to all medical emergencies, and ambulance transfer services between medical facilities. Ambulance personnel are extensively trained to nationally and internationally accepted standards, and collaborates and coordinates with all local health care facilities to ensure the best possible patient care. BERT is an International Training Organization for the American Heart Association, offering courses in First Aid, Cardio Pulmonary Resuscitation (CPR), Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Cardiac Life Support (PALS), Medical First Responder Training (MFR) and Emergency Medical Technician (EMT). BRITISH VIRGIN ISLANDS Peebles Hospital in the island of Tortola has an organized Accident and Emergency Department. It has not been possible to ascertain whether the Hospital has an Emergency Ambulance Service, or whether such service is provided by a private ambulance service. A private air ambulance service comprising aircraft used for emergency medical assistance in situations where traditional ambulances cannot easily reach the scene, are equipped with advanced cardiac life support systems and staffed with trauma experts, and stand ready to fly and transport persons in need of urgent medical attention, from any of the islands which make up the territory of the British Virgin Islands to the Peebles Hospital in the main island Tortola. DOMINICA The Fire and Ambulance Service Division falls under the Ministry of National Security, and is governed by Chapter 42:60 of the Laws of Dominica. The Princess Margaret Hospital is the major trauma facility in Dominica, with an accident and emergency department. The St. John Association of Dominica officially formed in 2002, arose from a group of concerned people known as the Emergency Medical Services Organisation of Dominica who saw significant benefits in being a part of a world wide family. The Association is responsible for establishing St, John Ambulance Dominica which is registered as a National Voluntary Organisation, incorporated under the Companies Act of Dominica on 14 August 2002 with Registration Number 1128. GRENADA The Hospitals Management Act (Chapter 135) of Grenada is an Act to make provision for the proper management of hospitals. It provides for the appointment of Chief Medical Officer in respect of each hospital, and the Chief Medical Officer shall be responsible for the treatment of all persons admitted to the hospital to which he is appointed. Section 15 which provides for urgent cases states that a person suffering from the effects of a severe accident or from disease threatening imminent LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 13

death and requiring prompt attention may be admitted into a hospital as a patient without any order or recommendation pending the arrival of a medical practitioner who shall determine whether it is necessary to detain such person in hospital. Section 20 states that the Ministry may from time to time make regulations and may thereby prescribe the carrying into effect of the general purposes of this Act. GUYANA The Regional Health Authorities Act 2005 (Act No. 4 of 2005) of Guyana establishes regional health authorities with responsibility for providing for the delivery of and administering health services and health programmes in specified geographic areas and for matters incidental thereto and connected therewith. Section 14(4) states that unless the power to delegate is limited by this Act or the regulations, a regional health authority may delegate any power or duty conferred or imposed on it under this Act or any other law to a committee of the regional health authority or to any of its officers. Section 23 states that a board may establish a professional advisory committee to advise the board with respect to (a) clinical care and health issues; (b) criteria for admission and discharge of patients; (c) quality assurance and management with respect to the health services and health programmes delivered by the regional health authority; and (d) any other issue that the board may refer to the committee. Section 37 states hat the Minister may make regulations to give effect to the provisions of this Act. The Ministry of Health Act, 2005 (Act No. 6 of 2005) of Guyana recognizes that the Ministry of Health is to deliver and where necessary oversee the delivery of health care throughout Guyana and to effect plans and policies, monitor quality and evaluate outcomes. Appropriately, therefore, in The National Health Sector Strategy 2008-1012 of Guyana reference is made to improving capacity to respond to emergencies, disasters, climate change and environmental health risks; and to intensify efforts by the Ministry of Health to deploy modern legislation, regulations and licensing, using professional codes of ethics, patient charters, standards and guidelines. These aspects of the National Health Sector Strategy 2008-1012 are particularly significant since no legislation appears to exist directly relating to disaster management and emergency response, or to emergency ambulance services. Clearly, however, Guyana is cognizant of the importance of these areas. Its Ministry of Health Act, 2005 (Act No. 6 of 2005) can in fact be consider as the umbrella Act for the establishment of a national emergency ambulance service. The Civil Defence Commission (CDC) is the organization responsible for the coordination of disaster management in Guyana. The CDC is currently developing an Integrated Development Risk Management Plan which would provide policy input for the eventual enactment of a Disaster Risk Management Act. JAMAICA The National Health Services Act, 1997 (Act No. 10 of 1997) repeals the Hospitals (Public) Act and provides for the establishment of regional health authorities to administer the nation s health services and facilities and for matters connected therewith or incidental thereto. Section 2 states that the Minister may, from time to time, prepare a scheme or schemes for the establishment and management of one or more regional health authorities. Section 5 states that a Regional Director shall be 14 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN

appointed by an Authority. A Regional Director shall be responsible for, among other things, directing and controlling the development of strategic and operational plans for health services in the region, as well as the coordination of activities of (i) all public health activities in the region; and (ii) such other agencies as may be responsible for the delivery of health services within that region; and the review and appraisal of all projects for the divestment of medical and non-medical services in the region, and such other duties as may from time to time be specified by the Authority. The Minister may make Regulations generally in respect of public health facilities, and any such regulations may relate generally to all public health facilities or to any particular health facility. In his 2008 Paper entitled The Evolution of Emergency Medicine in Jamaica, Dr. E.W. Williams of the Emergency Medicine Division of the University of the West Indies states that there is an urgent need for improvement in pre-hospital care, that this will require the development of an efficient Emergency Medical Service (EMS), and that more emphasis on and attention to disaster medicine is required. According to Dr. Williams, pre-hospital care was non-existent and medical treatment did not begin until a patient arrived at the hospital. He acknowledged, however, that in 1988 a new Accident and Emergency Unit was established at the University Hospital, which in 2008 was headed by a medical director with expertise in emergency medicine. The unit has also benefited from the addition of trained Emergency Room Technicians. In a joint venture between the Ministry of Health and the Jamaica Fire Brigade, firemen were trained as basic emergency medical technicians. Dr. Williams s Paper also indicates that, at the time of writing (2008), an Emergency Medical Services Bill was in the final stage of preparation, which could provide the legislative framework to expand the range of skills that may be performed by Emergency Medical Technicians, and will facilitate the training of Emergency Medical Technicians Intermediate and Emergency Medical Technicians Paramedic. MONTSERRAT The Public Health Act of 1982 (Chapter 14:01) of Montserrat confers on the Ministry of Health the responsibility for the public health of the population of Montserrat and establishes the Public Health Advisory Board. The functions of the Board are: to advise the Governor-in-Council, the Minister and the Chief Medical Officer; to make recommendations on any matter relating to public health in Montserrat; to exercise any powers conferred by this Act; and to discharge any functions delegated to it by the Minister. Glendon Hospital, St. John, has an Accident and Emergency Department, and provides an ambulance service. An on-line website indicates that PAHO/WHO CPCC s Health Systems Development program covering Barbados and the Easter Caribbean countries relates in part to Emergency Response and Disaster and Emergency Medical Services in Montserrat. It has not proved possible to consult a copy of the Development Program, but it is a reasonable assumption that it will be concerned with the existence of viable emergency ambulance services not only for Montserrat but also for Barbados and the other Eastern Caribbean countries. LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN 15

SAINT KITTS AND NEVIS Online sources indicate that in St. Kitts and Nevis the Joseph N. Franc General Hospital is the major trauma facility dealing with accidents and emergencies. Ambulance crew and Emergency Medical Technicians (EMT) are allowed to perform CPR and start IV lines. No indication is given in that source as to whether the EMTs operate under the authority of a medical doctor specializing in emergency medicine. SAINT LUCIA The Motor Ambulance Regulations, Statutory Instrument 10/1962 were made under the Hospitals Act, 1954, This Act was repealed and replaced by Public Hospitals (Management) Act. However, these Regulations are considered to continue in force by virtue of Section 28(3) of the Interpretation Act. The Regulations make no provision for pre-hospital emergency medical care or for the services of emergency medical technicians or paramedics. The ambulance is only for the transportation of the severely injured or urgently ill person to the Victoria Hospital. The Public Heath Act (Chapter 11.01) of St Lucia makes the Minister responsible for Health generally responsible for the promotion and preservation of the health of the inhabitants of Saint Lucia. The Minister is made responsible for the administration of the provisions of this Act. Section 5 states that the Minister shall establish a Public Health Board and may delegate to the Board such of his functions as he thinks fit. The Medical Officers Act (Chapter 11.05) provides for the appointment of the Chief Medical Officer by the Governor General. The Chief Medical Officer is ex officio a member of the Medical Board of St. Lucia, and has the general superintendence and direction of the public medical service of St. Lucia and of the several hospitals and medical establishments supported by the Government, and shall perform such other duties as the Governor General may direct. Under provisions set out in St Lucia s Disaster Management Act, 2006 (Act No. 30 0f 2006), the country s National Emergency Management Plan was revised on 20 January 2010. The Plan comprises several Policy Documents, among them being the Comprehensive Disaster Management Strategy, and the National Mass Casualty Management Plan. Section 11(3) of the Act states that the National Disaster Management Plan shall include (a) procedures for, mitigation of, response to and recovery from emergencies and disasters by public officers, Ministries and Departments of Government, statutory bodies, local government units, and persons or organization who volunteer or are required by law to perform functions related to the mitigation of, preparedness for response to and recovery from emergencies and disaster in Saint Lucia. The Plan is designed as the Official Guideline for National Coordination of all resources involved in emergency management and is to be referred to in any emergency situation. Other documents forming part of the National Disaster Management Plan, are: The Ministry of Health Disaster Plan; the National Mass Casualty Plan; and the National Mass Fatality Plan. Emergency response agencies in the case of amass casualty event are the Royal Police Force; the National Emergency Management Organization; the St Lucia Fire Service; the Ministry of Health; the St Lucia Red Cross Society; the St John s Ambulance Brigade; and the local ambulance service. 16 LEGISLATION STUDY ON EMERGENCY MEDICAL CARE SYSTEMS IN THE ENGLISH-SPEAKING CARIBBEAN